Dermatology Clinic of Muncie, Inc.

Primary specialty

Dermatology PhysicianTaxonomy code 207N00000X

License

50001481A Issued in IN

Legal business name

DERMATOLOGY CLINIC OF MUNCIE, INC.

Practice address

1808 W Royale Dr
Muncie, IN 47304-2243

Phone

(765) 288-8188

Fax

(765) 282-7242

NPI assigned

Oct 3, 2006

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Charles William Bartholome, MD

Title

President

Phone

(765) 288-8188

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Enrolled in IN

Enrollment records 1

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Locations

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Olivia Phillips, PA-C

  • Physician Assistant
  • Muncie, IN
  • NPI 1205649878
  Medicare reassignment NPD
• Gennady P Chernyak, PA

  • Physician Assistant
  • Muncie, IN
  • NPI 1487698072
  Medicare reassignment
• Christine Kirkendol Watson, M.D.

  • Internal Medicine Physician
  • Indianapolis, IN
  • NPI 1053361196
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159833600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1192665600000",
    "number": "1477647303",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1808 W ROYALE DR",
            "city": "MUNCIE",
            "state": "IN",
            "postal_code": "473042243",
            "telephone_number": "765-288-8188",
            "fax_number": "765-282-7242"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1808 W ROYALE DR",
            "city": "MUNCIE",
            "state": "IN",
            "postal_code": "473042243",
            "telephone_number": "765-288-8188",
            "fax_number": "765-282-7242"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DERMATOLOGY CLINIC OF MUNCIE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-03",
        "last_updated": "2007-10-18",
        "status": "A",
        "authorized_official_last_name": "BARTHOLOME",
        "authorized_official_first_name": "CHARLES",
        "authorized_official_middle_name": "WILLIAM",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "765-288-8188",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": "IN",
            "license": "50001481A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100105450",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Delaina Denny, RBT
• Dental Professionals of in, P.C.
• Dental Professionals of Indiana, P.C.
• Dental Professionals of Indiana, P.C.
• Dentistry for Children of Indiana, LLC
• Brenda Lynn Derry, ACIT II, MATS
• David M Dersch, MD
• Tanvi Anil Desai, M.D.
• Shae Leslie Desmond, CCC-SLP
• Jennifer Marie Detweiler

• Dermatology Physician in Muncie, IN
• Providers in Muncie, IN by specialty
• Dermatology Physician in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 18, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.